- Email: [email protected]
Left Perinephric Abscess Caused By Salmonella Enteritidis Due To Colon Perforation
0022-5347/03/1705-1945/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 170, 1945, November 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000089500.49469.97
LEFT PERINEPHRIC ABSCESS CAUSED BY SALMONELLA ENTERITIDIS DUE TO COLON PERFORATION ˙ TEVFIK, ˙ ˙ ERGIN ˙ ¨ LEYMAN KILIC ¨ SEYIN SU ¸ , MEHMET REFIK HU
AND
CAN BAYDI˙NC ¸
¨ zal Medical Center, Inonu University From the Departments of Urology (SK, HE, CB) and Microbiology (MRT), Turgut O School of Medicine, Malatya, Turkey KEY WORDS: Salmonella enteritidis, abscess etiology, intestinal perforation/complications
Perinephric abscess rarely results from gastrointestinal pathology.1 Additionally, the development of a perinephric abscess due to salmonella species is rare. To our knowledge this entity was finally reported in 1988 by Montesino Semper et al.2 We report a case of Salmonella enteritidis caused perinephric abscess resulting from a colonic perforation. Treatment involved percutaneous drainage combined with parenteral antibiotic and open surgery. CASE REPORT
A 21-year-old quadriplegic male complained of a cutaneous fistula draining greenish purulent material in the left lumbar region 2 weeks in duration. Two weeks previously he had experienced high fever for a period of 2 days. He had undergone percutaneous abscess drainage 4 times from the same region within the last 3 years but the etiology was unknown. At initial presentation he had no fever. Ultrasonography (USG) revealed a mass containing hypoechoic areas and mixed echoes around the left atrophic stony kidney, which were concordant with perinephric abscess. Enhanced computerized tomography (CT) without oral or rectal contrast material confirmed the sonographic findings (see figure). Empirical antibiotic treatment with ceftriaxone was started following routine laboratory examinations. CT guided percutaneous drainage was subsequently performed. Blood and urine cultures yielded no pathogens, but Salmonella enteritidis was detected in pus. Subsequent fecal culture showed normal flora. Accepted for publication June 13, 2003.
Since the abscess failed to resolve with conservative treatment, surgical drainage and nephrectomy were performed. Urgent laparotomy was performed on postoperative day 3 after feces discharged from the wound. Descending colon was adhesive to retroperitoneum. A small colonic perforation that occurred before our surgical intervention was thought to be the cause for abscess development. Resection and end-to-end anastomosis were performed. Postoperatively new wound infection developed. Following several wound de´bridements and revisions the patient recovered and was discharged home on postoperative day 59 after nephrectomy.
DISCUSSION
Although USG is useful, CT is the preferred method in the diagnosis of a perinephric abscess.2 CT is more accurate than USG for detection of abscesses, provides excellent anatomical detail, and clearly demonstrates the extent and route of the abscess and its relationship to nearby structures. Also, CT guidance is recommended for percutaneous drainage of abscesses. Administration of contrast material orally or rectally can increase the chance of diagnosing colonic perforation leading to abscess formation as in our case. Presence of a predisposing factor (stony kidney) for abscess development and absence of evidence of perforation such as gas bubbles in the abscess cavity led us not to perform intestinal contrast. Also, decompression of colon into the retroperitoneal and perinephric areas resulted in the absence of typical symptoms of peritonitis. Therefore, an early diagnosis of colonic perforation was not made, and this allowed extension of the infection into the retroperitoneal space, thus, making the condition more complicated. We suggest that even if there is a urogenital abnormality like stony kidney, or no finding of colonic perforation on USG, special evaluation of the gastrointestinal tract during radiological examinations is mandatory to determine causes of infection other than hematological and renal causes. This especially applies in cases of perinephric abscess caused by an unusual organism like salmonella rather than staphylococcus or uropathogens, which are the most common causes of perinephric abscesses.
REFERENCES
Enhanced computerized tomography shows perinephric abscess around left atrophic stony kidney.
1945
1. Kao, C. T., Tsai, J. D., Lee, H. C., Wang, N. L., Shih, S. L., Lin, C. C. et al: Right perinephric abscess: a rare presentation of ruptured retrocecal appendicitis. Pediatr Nephrol, 17: 177, 2002 2. Montesino Semper, M., Henraez Manrique, I., de Blas Bravo, M. and Matev Badia, J.: Perinephritic abscess due to salmonella: percutaneous drainage. Actas Urol Esp, 12: 481, 1988
Vol. 170, 1945, November 2003 Printed in U.S.A.
DOI: 10.1097/01.ju.0000089500.49469.97
LEFT PERINEPHRIC ABSCESS CAUSED BY SALMONELLA ENTERITIDIS DUE TO COLON PERFORATION ˙ TEVFIK, ˙ ˙ ERGIN ˙ ¨ LEYMAN KILIC ¨ SEYIN SU ¸ , MEHMET REFIK HU
AND
CAN BAYDI˙NC ¸
¨ zal Medical Center, Inonu University From the Departments of Urology (SK, HE, CB) and Microbiology (MRT), Turgut O School of Medicine, Malatya, Turkey KEY WORDS: Salmonella enteritidis, abscess etiology, intestinal perforation/complications
Perinephric abscess rarely results from gastrointestinal pathology.1 Additionally, the development of a perinephric abscess due to salmonella species is rare. To our knowledge this entity was finally reported in 1988 by Montesino Semper et al.2 We report a case of Salmonella enteritidis caused perinephric abscess resulting from a colonic perforation. Treatment involved percutaneous drainage combined with parenteral antibiotic and open surgery. CASE REPORT
A 21-year-old quadriplegic male complained of a cutaneous fistula draining greenish purulent material in the left lumbar region 2 weeks in duration. Two weeks previously he had experienced high fever for a period of 2 days. He had undergone percutaneous abscess drainage 4 times from the same region within the last 3 years but the etiology was unknown. At initial presentation he had no fever. Ultrasonography (USG) revealed a mass containing hypoechoic areas and mixed echoes around the left atrophic stony kidney, which were concordant with perinephric abscess. Enhanced computerized tomography (CT) without oral or rectal contrast material confirmed the sonographic findings (see figure). Empirical antibiotic treatment with ceftriaxone was started following routine laboratory examinations. CT guided percutaneous drainage was subsequently performed. Blood and urine cultures yielded no pathogens, but Salmonella enteritidis was detected in pus. Subsequent fecal culture showed normal flora. Accepted for publication June 13, 2003.
Since the abscess failed to resolve with conservative treatment, surgical drainage and nephrectomy were performed. Urgent laparotomy was performed on postoperative day 3 after feces discharged from the wound. Descending colon was adhesive to retroperitoneum. A small colonic perforation that occurred before our surgical intervention was thought to be the cause for abscess development. Resection and end-to-end anastomosis were performed. Postoperatively new wound infection developed. Following several wound de´bridements and revisions the patient recovered and was discharged home on postoperative day 59 after nephrectomy.
DISCUSSION
Although USG is useful, CT is the preferred method in the diagnosis of a perinephric abscess.2 CT is more accurate than USG for detection of abscesses, provides excellent anatomical detail, and clearly demonstrates the extent and route of the abscess and its relationship to nearby structures. Also, CT guidance is recommended for percutaneous drainage of abscesses. Administration of contrast material orally or rectally can increase the chance of diagnosing colonic perforation leading to abscess formation as in our case. Presence of a predisposing factor (stony kidney) for abscess development and absence of evidence of perforation such as gas bubbles in the abscess cavity led us not to perform intestinal contrast. Also, decompression of colon into the retroperitoneal and perinephric areas resulted in the absence of typical symptoms of peritonitis. Therefore, an early diagnosis of colonic perforation was not made, and this allowed extension of the infection into the retroperitoneal space, thus, making the condition more complicated. We suggest that even if there is a urogenital abnormality like stony kidney, or no finding of colonic perforation on USG, special evaluation of the gastrointestinal tract during radiological examinations is mandatory to determine causes of infection other than hematological and renal causes. This especially applies in cases of perinephric abscess caused by an unusual organism like salmonella rather than staphylococcus or uropathogens, which are the most common causes of perinephric abscesses.
REFERENCES
Enhanced computerized tomography shows perinephric abscess around left atrophic stony kidney.
1945
1. Kao, C. T., Tsai, J. D., Lee, H. C., Wang, N. L., Shih, S. L., Lin, C. C. et al: Right perinephric abscess: a rare presentation of ruptured retrocecal appendicitis. Pediatr Nephrol, 17: 177, 2002 2. Montesino Semper, M., Henraez Manrique, I., de Blas Bravo, M. and Matev Badia, J.: Perinephritic abscess due to salmonella: percutaneous drainage. Actas Urol Esp, 12: 481, 1988